Medically necessary

Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.

When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator, may be used.

CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at

https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html

Medical, surgical, mental health and substance use disorder Aetna POS II A/B network

 

If you use In-network providers

The Aetna Choice® POS II network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service are located throughout the United States. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the Plan money. Other advantages to using Medical POS II network providers for medical, mental health and substance use disorder care are:

• You pay a copay for most office visits, including diagnostic laboratory and X-rays associated with that office visit. Preventive care office visits are reimbursed at 100%.
• Emergency room physician expenses, in-patient hospital expenses, and outpatient surgery expenses are subject to deductible and coinsurance.
• Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the Aetna POS II B or 75% for the Aetna POS II A) of a negotiated rate after you meet the annual deductible.
• Your annual out-of-pocket maximum is significantly lower.
• Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
• All negotiated charges are within reasonable and customary limits.

To find Aetna Choice® POS II network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.

Copayment for office visits/lab work when provided by a primary care physician; higher copayment when provided by a specialist.

When you use Medical POS II network providers for office visits, you are not subject to the annual deductible. You pay a copayment for each office visit, which may include  related lab work and radiology performed by a POS II network provider.

More extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, and office or out-patient surgery and associated diagnostic lab and xray services are subject to the deductible and coinsurance.

If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the copayment will be the actual cost of the injection or the office visit copayment, whichever is less. For infusion therapy and chemotherapy, a fixed copayment only applies to the office visit. All other related services are subject to the plan’s deductible and/or coinsurance. Allergy serum dispensed by a network doctor is reimbursed at coinsurance after the deductible.

These copayments do not apply to your annual deductible but do apply to your annual out-of-pocket limit. See the explanation beginning in the Payment section for more information about deductibles and copayments.

Is your doctor a network provider?

Call your doctor's office to confirm their participation in the Aetna Choice® POS II network. If your doctor is not participating, ask your provider to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's website (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232. 

If you live in a medical POS II network area and use medical POS II non-network providers:

• Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the Aetna POS II B and 55% for the Aetna POS II A of reasonable and customary charges, after you satisfy the non-network deductible, and your out-of-pocket expenses will accumulate towards a higher non-network out-of-pocket maximum.    
• You must call Aetna to initiate the medical pre-admission review process for inpatient treatment and ensure any precertification or preauthorization requirements are completed.    
• If your provider or facility charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits in addition to your deductible and/or coinsurance. You may be balance billed by the provider or facility for any amount not reimbursed by Aetna.Refer to section regarding non-volitional use of non-network providers for additional details.
• You are responsible for submitting claims.

If you cannot find a Network Provider (network deficiency)

Sometimes you may have difficulty finding a network provider in your area that is available when you need care. If an Aetna Choice® POS II network provider is not available for medical, surgical, mental health and substance use disorder services, call Aetna Member Services for information on the Plan's alternate network deficiency benefit. If Aetna confirms a network provider is not available for the services you need, they will authorize use of a designated non-network provider for your care.

Benefits for covered services at a designated non-network provider under the alternate network deficiency benefit will be paid at the In-Network level (either 80% for Aetna POS II B or 75% for Aetna POS II A of reasonable and customary charges) after the plan year deductible has been satisfied, and out-of- pocket expenses for those services will accumulate towards your In-Network out-of-pocket maximum. Copayments will not apply.

If you live outside a Aetna POS II network area (out-of-network area benefits)

If you live outside a designated POS II network area, benefits for covered services are paid at the out-of-network area benefit level.

You still have access to Aetna Choice® POS II network providers and facilities in your area, within a short driving distance, and while travelling. When you receive care from a network provider or in a network facility, you will be reimbursed at 80% for Aetna POS II B or 75% for Aetna POS II A of the negotiated network rate for inpatient and outpatient services, your network provider will initiate the pre-admission review process, and network copayments for primary care and specialist office visits will apply.

If you live outside a POS II network area and receive care from a non-network provider or in a non-network facility, you will be reimbursed at 80% for Aetna POS II B and 75% for Aetna POS II A of reasonable and customary charges for similar services in the same area. Network discounts and network copayments do not apply, and you must satisfy the deductible for all covered services other than preventive care. You are also responsible for initiating the medical pre-admission review process for inpatient treatment unless you use a network provider.

Most non-network charges fall within reasonable and customary limits. However, you may receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services in your area. If this happens, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available. However, if a network physician is available and you schedule an inpatient or outpatient procedure with a non-network physician, you will be responsible for any billed charges above reasonable and customary limits, which for professional services is set at 200% of Medicare Fee Schedule of charges for similar services in the same geographic area.

If you live outside a POS II network area, the out-of-pocket maximum for non-network services is the same as the maximum for network services. Once your annual out-of-pocket limit is reached, covered services are reimbursed at 100% of reasonable and customary charges.

Note: You are responsible for payment for services that are not covered by the Plan, including non-medical ancillary services and any balance bill that remains after adjustments for allowable expenses have been made. Payments for services not covered by the Plan do not accumulate towards your annual out-of-pocket limit.

Effective January 1, 2023, If you incur claims outside of the U.S., no reimbursement is paid for non-emergency care.  

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or balance billing.

For more information on your rights, please refer to the Surprise Medical Bills notice located in www.exxonmobilfamily.com

Your ID cards

Your cards identify you as a plan participant when you receive services from in-network providers or when you receive emergency services at non-network facilities. Always carry your ID cards with you and show them each time you get covered services from a provider, including your prescription drug card (Express Scripts).

If your cards are lost or stolen, please notify Aetna and Express Scripts immediately.